- Email: [email protected]
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
WOMEN'S HEALTH WOMEN'S HEALTH
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy Dominique Bourassa, MD, Jocelyn Bérubé, MD, MSc Clinique de planification des naissances, Rimouski (Québec)
Abstract Objective: To determine the prevalence of intimate partner violence (IPV) among women and teenagers seeking termination of pregnancy compared with those continuing with pregnancy. Methods: All women who presented for elective termination of pregnancy at a family planning clinic between June 2001 and January 2003 were invited to participate. This study was conducted by means of face-to-face interviews with clinic nurses. The control group was composed of women who were continuing with pregnancy. Results: In total, 1003 women were interviewed, including 350 at the family planning clinic (elective abortion [EA] group) and 653 women at the perinatal clinic (continuing pregnancy [CP] group). For women in the EA group, the probability of being a victim of IPV in the past year (including psychological, physical, and/or sexual abuse) was almost three times higher than for women in the CP group (25.7% vs. 9.3%, P < 0.0001), and the risk of being a victim of physical and/or sexual IPV in the past year was almost four times higher (7.1% vs. 1.8%, P < 0.0001). Women in the EA group had also more often been victims of violence in their lifetime (41.1% vs. 29.1%, P = 0.0001). The principal factors predictive of having been a victim of physical and/or sexual IPV in the past year were being single, separated, divorced, or widowed, and being in a relationship that was in difficulty or breaking down. In the multivariate analysis adjusted for confounding factors, age was rarely a significant factor. Conclusion: The high prevalence rates of IPV among women seeking elective abortion justifies routine assessment for IPV during pre-abortion visits. Physicians have access to tools that will help them to identify IPV and to be proactive regarding this important issue.
Key Words: Intimate partner violence, elective abortion, pregnancy, teenagers Competing Interests: None declared. Received on December 1, 2006 Accepted on February 12, 2007
Résumé Objectif : Déterminer la prévalence de la violence exercée par le partenaire intime (VPI) chez les femmes et les adolescentes qui cherchent à obtenir une interruption de grossesse, par comparaison avec celles qui souhaitent poursuivre leur grossesse. Méthodes : Toutes les femmes qui se sont présentées, entre juin 2001 et janvier 2003, dans une clinique de planification familiale afin d’obtenir une interruption volontaire de grossesse ont été invitées à participer à l’étude. Celle-ci a été menée au moyen d’entrevues directes avec des infirmières cliniques. Le groupe témoin était composé de femmes qui poursuivaient leur grossesse. Résultats : Au total, 1 003 femmes ont été interviewées, dont 350 qui l’ont été à la clinique de planification familiale (groupe « interruption volontaire de grossesse » [IVG]) et 653, à la clinique périnatale (groupe « poursuite de la grossesse » [PG]). Dans le cas des femmes du groupe IVG, la probabilité d’avoir été victime de VPI (y compris la violence psychologique, physique et/ou sexuelle) au cours de l’année précédente était près de trois fois plus élevée que pour les femmes du groupe PG (25,7 %, par comparaison avec 9,3 %, P < 0,0001), tandis que le risque d’avoir été victime de VPI physique et/ou sexuelle au cours de l’année précédente était près de quatre fois plus élevé (7,1 %, par comparaison avec 1,8 %, P < 0,0001). Les femmes du groupe IVG avaient également été plus souvent victimes de violence au cours de leur vie (41,1 %, par comparaison avec 29,1 %, P = 0,0001). Les principaux facteurs permettant de prédire le fait que la patiente avait été victime de VPI physique et/ou sexuelle au cours de l’année précédente étaient le célibat, la séparation, le divorce ou le veuvage, ainsi que le fait de vivre une relation connaissant des difficultés ou se détériorant. Dans le cadre de l’analyse multivariée ayant fait l’objet d’une neutralisation des facteurs confusionnels, l’âge constituait rarement un facteur significatif. Conclusion : Les taux élevés de prévalence de la VPI chez les femmes cherchant à obtenir une interruption volontaire de grossesse justifie le recours systématique à une évaluation de la VPI au cours des consultations préavortement. Les médecins ont accès à des outils pouvant les aider à identifier la présence de VPI et à agir de façon préventive à l’égard de cet important problème. J Obstet Gynaecol Can 2007;29(5):415–423 MAY JOGC MAI 2007 l
415
WOMEN'S HEALTH
INTRODUCTION
ntimate partner violence (IPV) is widely recognised as a major social and public health issue. IPV includes psychological, verbal, physical, and sexual abuse, as well as economic deprivation or financial abuse. It does not result from loss of control; rather, it is a way chosen to dominate and assert power over another person. It can be experienced at any age, in either a marital or an extramarital relationship. Violence is a significant cause of morbidity and mortality for women, and women experiencing violence have an increased incidence of substance abuse, mental disorders, chronic physical disorders, and sexual complaints.1
I
Many studies have shown that prevalence rates for violence among pregnant and adolescent women appear to be greater than in non-pregnant women; Canadian surveys of violence against women have found an annual prevalence of 8%, and in a sub-group of women who were abused during pregnancy, 40% reported that the abuse began during pregnancy.2 Studies on this topic in the United States have indicated that the prevalence of domestic violence during pregnancy ranges from 0.9% to 20.1%,3 and women with unplanned pregnancies were four times more likely to be a victim of physical violence (12.1% vs. 3.2%).4 Parker et al. reported that 21% of adolescent females and 14% of adult women report experiencing domestic violence during pregnancy.5 In Canada, the prevalence of physical abuse before pregnancy ranges from 8.5% to 10.9%; during pregnancy, it varies between 5.7% and 6.6%.6,7 Indeed, pregnant women are at greater risk of being victims of domestic violence than they are of developing hypertension, preeclampsia, gestational diabetes, or other prenatal complications for which screening is routine and well-organized.3,8 Women who seek termination of pregnancy seem to be particularly at risk of physical abuse; most pregnancies in these women are unplanned. One study in the US identified a 7.8% rate of physical or psychological abuse during pregnancy, and a prevalence of 21.6% in the previous year9; another described an overall rate of psychological, physical, and sexual violence (including lifetime abuse) of 39.5%.10 In a study conducted in an abortion clinic in British Columbia, the reported rates of physical and sexual violence during the preceding year were 8.3% and 7.1%, respectively; 8.3% of women said that they were afraid of their partners.11 A study of 1145 women presenting to abortion clinics in Ontario showed that more than one quarter of them (26.4%) reported significant conflict in their relationship with the man involved in their pregnancy, 19.5% reported having been physically abused at least once by a male partner, and 27% reported that they had experienced sexual abuse or sexual violence in the past.12 416
l MAY JOGC MAI 2007
The objective of this study was to determine the prevalence of intimate partner violence in women seeking termination of pregnancy and to compare it with the prevalence in women who continued with pregnancy. METHODS
All women who presented for voluntary termination of pregnancy at the Rimouski family planning clinic between June 2001 and January 2003 were invited to participate in this study. We opted to administer the questionnaires during patients’ face-to-face interviews with the clinic nurses (private interview and anonymous questionnaire) rather than offer the women a questionnaire to complete, given the higher rates of disclosure of violence discovered in studies that used the former interview technique.13 The control group comprised pregnant women who chose to continue their pregnancy; all women who met with the perinatal nurse for their routine interview, usually during the first trimester, were invited to participate in the study. The two nurses at the family planning clinic and the perinatal nurse had been given training in routine assessment and intervention for victims of IPV, as well as in interviewing participants using the questionnaire. Flyers on the subject of IPV and available resources were given to all participants after the interview. Women who were identified as victims of IPV were offered follow-up with the family planning clinic’s social service professional, as well as more detailed verbal explanations of various subjects related to IPV (types of violence, cycle of violence, escalation, and protection scenario). The study questionnaire was adapted from the Abuse Assessment Screen, a previously validated screening instrument frequently used in studies of IPV (Appendix). A section on sociodemographic data was added to the questionnaire, as well as a question on psychological violence. Three dependent variables were analyzed in this study: victims of lifetime abuse (who answered yes to question 1); victims of intimate partner violence within the last year (who answered yes at least once to at least one of questions 2, 3, and 5 [question 4 is included in question 3], indicating if it was their partner or ex-partner); and victims of physical and/or sexual intimate partner violence within the last year (who answered yes to questions 3 or 5, indicating if it was their partner or an ex-partner). Simple associations between sociodemographic variables and dependent variables were first measured with the chi-square test for each variable individually (univariate analysis). Subsequently, the joint effect of each variable for which a simple association had been detected was measured using logistic regression models (multivariate analysis). All statistical tests were performed with a threshold for significance of 5%.
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
RESULTS
Two women who chose abortion and two who chose to continue their pregnancies refused to participate. In total, 1003 women were interviewed, including 350 at the family planning clinic (elective abortion [EA] group) and 653 women at the perinatal clinic (continued pregnancy [CP] group). The demographic characteristics of participants are presented in Table 1. Women in the EA group differed on all points from the CP group: they were younger, more often single or in a relationship that was in difficulty or breaking down, were less educated, and had lower incomes. They were more likely to have had a previous abortion, and their current pregnancy was more likely to be unplanned. The prevalence of different types of violence is shown in Table 2. Women in the EA group were at significantly greater risk of having been victims of most types of abuse measured, including lifetime abuse, and of psychological, physical, and sexual abuse in the past year, and they were also more likely to express fear. The prevalence of physical abuse during pregnancy was similar in each group. In most cases, partners and ex-partners were responsible for the violent actions. Of women who identified their partners and/or ex-partners as the perpetrators of the acts of violence, women in the EA group were at higher risk, with a prevalence ratio of 1.41 for lifetime abuse, 2.75 for IPV in the past year, and 3.88 for physical and/or sexual IPV in the past year. The distribution of domestic violence variables is shown in Figure 1. Factors predictive of having been a victim of physical and/or sexual IPV in the past year (odds ratio) are shown in Table 3. Single women and women who were separated, divorced, or widowed were at significantly higher risk of having experienced abuse in the past year, particularly among the CP group. The other principal predictive factors were being in a relationship that was in difficulty or that was breaking down, the number of pregnancies, and having planned the pregnancy and being in the EA group. Concerning the variable “pregnancy planned,” 50% of the 12 women who had planned their pregnancy and were seeking termination had been victims of physical and/or sexual IPV in the past year; this figure contrasts with 5.6% among the 337 women whose pregnancy had not been planned and who were seeking termination. The trend was reversed for the group who continued their pregnancy (Table 4). Because there were few young adolescents in each group, we included them with young women aged 18–19 years to increase the statistical strength of the analyses related to the variable “patient’s age.” In the group of women seeking elective abortion, those under 20 years of age had less often been victims of lifetime abuse and of IPV (psychological,
physical, or sexual) in the past year than older women, but there was no significant difference regarding the variable physical and/or sexual IPV in the past year. Women under 20 years of age who continued their pregnancies had more often been victims of lifetime abuse than their older counterparts and than women under 20 who sought elective abortion (50% vs. 26.9%). In the group pursuing pregnancy, the prevalence of domestic abuse in the past year (psychological, physical, or sexual) and of domestic physical, and/or sexual abuse in the past year were higher in women under 25 years of age than in older women (Figure 2 and Tables 5, 6, and 7). In the multivariate analysis adjusted for confounding factors, association with age was rarely significant. DISCUSSION
Routine assessment for intimate partner violence, especially among pregnant women, has been recommended by a number of organizations, including the Society of Obstetricians and Gynaecologists of Canada in 1996 and again more recently in their Intimate Partner Violence Consensus Statement.1 To our knowledge, this study is the first that was designed to compare women seeking abortion with women continuing pregnancy. It is also the first profile concerning IPV for pregnant women and teenagers in Quebec. The risk of being a victim of IPV in the past year (including psychological, physical, and/or sexual abuse) was almost three times higher for women in the EA group than for women in the CP group, and the risk of being a victim of physical and/or sexual intimate partner violence in the past year was almost four times higher. These women have also more often been victims of lifetime violence. This situation can be partly attributed to the demographic characteristics of women in the EA group, who were more often separated, divorced, or widowed and more often in a relationship that was in difficulty or breaking down (corresponding to the major predictive factors listed in Table 3). We can also presume that a woman who is victim of IPV might have less control over choice of contraceptive method, and even less so in a context of sexual abuse, thus leading to a greater proportion of unplanned or unwanted pregnancies and women seeking a termination of pregnancy. Of the 466 women with unplanned pregnancies, 337 (72%) sought elective abortion. Several earlier studies on the prevalence of domestic abuse in a context of prenatal visits had listed unplanned pregnancy among the risk factors for abuse; in one of these, the risk of violence in a sub-group of women with unplanned pregnancies was four times higher.3 In our study, the prevalence of domestic abuse among women who continued their pregnancy was indeed much higher for those whose pregnancy had been unplanned than for women whose pregnancy was planned (7.8% vs. 0.4%). MAY JOGC MAI 2007 l
417
WOMEN'S HEALTH
Table 1. Comparative sociodemographic data for women who had elective abortions (EA) versus those who continued their pregnancies (CP) EA Group Sociodemographic data Woman’s average age Civil status Single Married Commom law Separated Divorced Widow Level of education Primary Secondary (regular) Secondary (professional / adult) College University Personal income Less than $999 $1000 to $9999 $10 000 to $19 999 $20 000 to $29 999 $30 000 to $39 999 $40 000 to $49 999 $50 000 and over Number of pregnancies 1 2 3 4 5 6 7 8 9 10 Previous elective abortions 0 1 2 3 4 5 Average age of partner Age of the pregnancy 5 to 9 weeks 10 to 14 weeks 15 to 26 weeks 27 to 36 weeks Pregnancy planned Yes No State of the couple Stable In difficulty Separating Separating eventually Does not apply
n
l MAY JOGC MAI 2007
%
n
Statistics %
c2 P < 0.0001 P < 0.0001
28.0
25.3 189 20 104 27 9 1
54.0 5.7 29.7 7.7 2.6 0.3
62 139 441 5 6 0
9.5 21.3 67.5 0.8 0.9 0.0
79 116 43 79 33
22.6 33.1 12.3 22.6 9.4
69 117 89 187 191
10.6 17.9 13.6 28.6 29.2
51 91 128 43 25 6 6
14.6 26.0 36.6 12.3 7.1 1.7 1.7
42 88 188 134 115 56 30
6.4 13.5 28.8 20.5 17.6 8.6 4.6
143 72 67 39 14 8 3 3 1 0
40.9 20.6 19.1 11.1 4.0 2.3 0.9 0.9 0.3 0.0
253 214 108 36 26 11 4 0 0 1
38.7 32.8 16.5 5.5 4.0 1.7 0.6 0.0 0.0 0.2
243 79 21 5 1 1 28.1
69.4 22.6 6.0 1.4 0.3 0.3
555 75 18 2 1 2 30.9
85.0 11.5 2.8 0.3 0.2 0.3
241 104 0 0
69.9 30.1 0.0 0.0
89 493 47 24
13.6 75.5 7.2 3.7
12 337
3.4 96.6
522 129
80.2 19.8
211 27 45 9 58
60.3 7.7 12.9 2.6 16.6
619 12 19 1 2
94.8 1.8 2.9 0.2 0.3
P < 0.0001
P < 0.0001
P < 0.0001
P < 0.0001
P < 0.0001 P < 0.0001
P < 0.0001
Missing values have been removed from the totals.
418
CP Group
P < 0.0001
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
Table 2. Detailed distribution of rates of violence Elective abortion (350)
Q-1 Victim of lifetime abuse Q-2 Psychological abuse past year (total) partner/ex-partner parent stranger others Q-3 Physical abuse, past year (total) partner/ex-partner parent stranger others Q-4 Physical abuse during pregnancy (total) partner/ex-partner parent others Q-5 Sexual abuse, past year (total) partner/ex-partner others Q-6 Fear (total) partner/ex-partner parent stranger others Variable: “Intimate partner violence in the past year” Variable: “Physical and/or sexual intimate partner violence in the past year”
Continuing pregnancy (653)
P
%
n
%
n
41.14%
(144)
29.10%
(190)
0.0001*
36.57%
(128)
19.60%
(128)
< 0.0001*
25.43% 2.60% 2.30% 6.20%
(89) (9) (8) (22)
9.20% 3.10% 0.90% 6.30%
(60) (20) (6) (41)
< 0.0001*
7.71%
(27)
2.30%
(15)
< 0.0001*
5.71% 0.30% 0.90% 0.30%
(20) (1) (3) (1)
1.50% 0.20%
(10) (1)
0.0002*
0.60%
(4)
1.14%
(4)
1.23%
(8)
1.000*
0.86% 0.30%
(3) (1)
0.80%
(5)
1.000*
0.50%
(3)
4.30%
(15)
0.60%
(4)
< 0.0001*
3.20% 1.10%
(11) (4)
0.50% 0.20%
(3) (1)
0.0003*
12.03% 8.60% 0.90% 0.30% 1.70% 25.71%
(42) (30) (3) (1) (6) (90)
7.20% 4.90% 1.80%
(47) (32) (12)
0.0140*
0.20% 9.34%
(1) (61)
P < 0. 0001*
7. 14%
(25)
1.84%
(12)
P < 0. 0001*
*Calculated using Fisher exact test
However, this association was reversed among women who had sought abortions. It is interesting to note that the prevalence of physical and/or sexual IPV in the past year is similar for women with an unplanned pregnancy in each group studied. In the analysis of the factors predictive of being a victim of physical and/or sexual IPV in the past year, only having a planned pregnancy in the EA group was significant, with an odds ratio of 16.05. Of the eight women who had been victims of physical and/or sexual IPV in the past year and who had planned their pregnancy, six sought termination. We can hypothesize that these women, once pregnant, decided not to bring a child into the world under conditions of violence.
Rates of physical abuse during pregnancy were similar in each group (1.14% in the EA group and 1.23% in the CP group), and were lower than those reported by Muhajarine7 (adjusted rate of physical violence during the second and third trimesters of pregnancy 4.5%) and Stewart6 (physical abuse during pregnancy 6.6%). Notably, our interviews with all women in the EA group and with 89.1% of women in the CP group were conducted in the first trimester; the prevalence of violence during pregnancy for the CP group might have been higher if the interviews had been repeated later in pregnancy. In the EA group, the prevalence of physical abuse in the past year was 7.7%, for sexual abuse in the past year was MAY JOGC MAI 2007 l
419
WOMEN'S HEALTH
Figure 1. Prevalence of Intimate Partner Violence (IPV) Variables
Figure 2. Lifetime Abuse Prevalence, by Patient's Age
4.3%, and 8.6% reported being afraid of their partner or ex-partner. These rates are comparable to those found in a study undertaken at a Vancouver abortion clinic.10 Prevalence rates for lifetime abuse in the EA group (41.4%) and the CP group (29.1%) were similar to those obtained in abortion clinics in the United States (39.5%)9 and in England (35.1%).14 At the outset, we hypothesized that teenagers who sought abortion were at greater risk of being victims of violence (physical, sexual, and psychological abuse). Instead, we observed the opposite in the EA group, with the prevalence of different types of abuse increasing with age (Tables 5, 6, and 7). Instead, the CP group of women under 20 had the highest prevalence of lifetime abuse. In the multivariate analysis adjusted for confounding factors, the association 420
l MAY JOGC MAI 2007
between age and abuse was rarely significant. The reported association between age and prevalence of abuse is variable, with some studies reporting a higher prevalence of physical abuse among younger women,6,15–17 and others finding no association.7,18,19 Our study has certain limitations. Underreporting is the first bias that can be identified in a study on the prevalence of IPV. We attempted to weaken this bias by opting for direct interviews, which have been shown to increase reporting rates.13 The second question used on the Abuse Assessment Screen (on psychological abuse) was not validated, unlike the five other questions. For this reason, we performed our analyses, including the multivariate analysis to determine the odds ratio, using the variable “physical and/or sexual IPV in the past year.” Finally, the variable “lifetime abuse”
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
Table 3. Odds ratios for factors predictive of having been a victim of physical and/or sexual abuse in the past year (multivariate analysis) Demographic variable
Elective abortion
19 years old and under*
0.24 (0.04–1.51)
20–24 years old*
0.44 (0.10–1.87)
25–29 years old*
0.72 (0.17–3.03)
Continuing pregnancy
30–34 years old*
0.06 (0.01–0.77)
Single†
3.02 (0.72–12.62)
21.29 (1.94–233.36)
Separated-divorced-widowed†
6.65 (1.22–36.26)
25.72 (1.15–573.36)
2nd pregnancy‡
8.44 (1.95–36.60)
2.78 (0.35–21.91)
3rd pregnancy‡
4.58 (0.96–21.85)
11.76 (1.45–95.11)
4th pregnancy‡
6.17 (1.30–29.40)
7.58 (0.82–70.02)
23.36 (4.85–112.59)
0.275 (0.05–1.55)
Pregnancy planned§ Pregnancy unplanned2
0.04 (0.01–0.21)
3. 64 (0.65–20.41)
Couple having difficulties¶
4.57 (1.08–19.35)
10.72 (1.29–89.07)
Couple separating¶ (include separating eventually)
4.39 (1.42–3.56)
8.49 (1.48–48.69)
Data presented according to odds ratio estimates (95% Wald confidence limits). *reference category is “over 35 years old” †reference category is “married/common-law” ‡reference category is “1st pregnancy” §reference category is “pregnancy unplanned” 2reference category is “pregnancy planned” ¶reference category is “stable couple” Data in bold are statistically significant.
Table 4. Prevalence of domestic physical and/or sexual abuse in the past year, according to whether or not the pregnancy was planned Victim of domestic physical and/or sexual abuse in the past year Elective abortion (25)
Continuing pregnancy (12)
P
Pregnancy planned (534)
50% (6/12)
0.4% (2/522)
< 0.0001*
Pregnancy unplanned (466)
5.6% (19/337)
7.8% (10/129)
0.40
P < 0.0001*
P < 0.0001*
Statistical tests *Calculated using Fisher exact test
does not include women who answered “no” to the first question (lifetime violence) and “yes” to the other questions (psychological, physical, or sexual abuse within the last year). Therefore, it is possible that women who were abused but did not consider themselves to be may not have been accounted for in the analyses. However, after examining the questionnaires, we found that only five women from the EA group and four from the CP group provided this pattern of answers; this would not have significantly changed the total number of positive responses to the first question. Women who are abused during pregnancy are more likely to be depressed and suicidal and to experience pregnancy
complications and poor outcomes, including maternal and fetal death.1 Certain risk factors identified in this study could be used as indicators (single, separated/ divorced/widowed, unplanned pregnancy, relationship in difficulty or breaking down), but there is no typical portrait of women who are victims of violence. One study has shown that women who had been given advice during their pregnancy on how to ensure their safety in situations of violence were subsequently able to reduce their exposure to violence.5 Larger studies should continue to evaluate effective strategies and preventive measures. But while waiting for definitive studies before attempting MAY JOGC MAI 2007 l
421
WOMEN'S HEALTH
Table 5. Prevalence of lifetime abuse, by patient’s age Victim of lifetime abuse Patient’s age
Elective abortion
Continuing pregnancy
P
19 years and under
26.9% (18/67)
50% (9/18)
0.11
20–24 years
39.7% (50/126)
40.6% (58/143)
0.98
25 years and over
48.4% (76/157)
25% (123/492)
0.0000001
P = 0.01
P = 0.0002
Statistical tests
Table 6. Prevalence of intimate partner violence in the past year, by patient’s age Victim of intimate partner violence in the past year Patient’s age
Elective abortion
Continuing pregnancy
P
19 years and under
16.4% (11/67)
11.1% (2/18)
0.726*
20–24 years
22.2% (28/126)
18.2% (26/143)
0.50
25 years and over
32.5% (51/157)
6.7% (33/492)
< 0.0001
P = 0.022
P = 0.0002
Statistical tests *Calculated using Fisher exact test
Table 7. Prevalence of physical and/or sexual intimate partner violence in the past year, by patient’s age Victim of physical and/or sexual intimate partner violence in the past year Paent’s age
Elective abortion
Continuing pregnancy
P
19 years and under
4.5% (3/67)
5.6% (1/18)
0.621*
20–24 years
6.4% (8/126)
5.6% (8/143)
0.997
25 years and over
8.9% (14/157)
0.6% (3/492)
< 0.0001*
P = 0.453
P = 0.0002
Statistical tests *Calculated using Fisher exact test
interventions, we must not ignore the ability of victims themselves to find solutions. Simple identification of the problem and a supportive relationship with a physician may help women to leave a dangerous situation or to reduce harm to themselves and their children.20 Training programs on assessment and interventions for victims of IPV should be easier to access and adapted to the needs of different health professionals, including physicians. The instrument used in this study and adapted from the Abuse Assessment Screen includes only six questions to ask the patient when her partner is not with her; it is quick and easy to use. Other tools are easily accessible, including the IPV Assessment Toolkit1 available on the SOGC website. Flyers on IPV are available in French and English 422
l MAY JOGC MAI 2007
from the websites of the Family Planning Clinic in Rimouski,21 the Peel Committee Against Woman Abuse,22 and the Metropolitan Action Committee on violence against women and children.23 CONCLUSION
Putting an end to violence against women and children is everyone’s responsibility. Given the high prevalence rates of intimate partner violence among women seeking elective abortion, we believe that assessment for IPV during pre-abortion visits is justified, as it is during prenatal routine visits. Physicians and all other health care providers now have access to tools that enable them to be proactive on IPV.
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
12. Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D. Characteristics of women undergoing repeat induced abortion. CMAJ 2005;172(5):637–41.
REFERENCES 1. Cherniak D, Grant L, Mason R, Moore B, Pellizzari R. Intimate partner violence consensus statement. SOGC Clinical Practice Guidelines, No. 157, April 2005. J Obstet Gynaecol Can 2005;27(4):365–88. Available at: http://www.sogc.org/guidelines/index_e.asp#SSI. Accessed March 11, 2007. 2. Burge VP, Locke D, eds. Family violence in Canada: a statistical profile. Ottawa: Canadian Centre for Justice Statistics, Statistics Canada; 2000. 3. Gazmarian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275(24):1915–20. 4. Gazmarian JA, Adams MM, Saltzman LE, Johnson, CH. Bruce FC, Marks JS. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85(6):1031–8. 5. Parker B, McFarlane J, Soeken K, Silva C, Reel S. Testing an intervention to prevent further abuse to pregnant women. Res Nurs Health 1999;22:59–66. 6. Stewart DE, Cecutti A. Physical abuse in pregnancy. CMAJ 1993;149(9):1257–63. 7. Muhajarine N, D’Arcy C. Physical abuse during pregnancy: prevalence and risk factors. CMAJ 1999;160(7):1007–11. 8. Health Canada. A handbook for health and social service professionals responding to abuse during pregnancy. Ottawa, Minister of Public Works and Government Services, Canada; 1999. 9. Evins G, Chescheir Nl. Prevalence of domestic violence among women seeking abortion services. Women’s Health Issues 1996;6:204–10. 10. Glander SS, Moore ML, Michielutte R, Parsons LH. The prevalence of domestic violence among women seeking abortion. Obstet Gynecol 1998;91(6):1002–6. 11. Wiebe ER, Janssen P. Universal screening for domestic violence in abortion. Women’s Health Issues 2001;11(5):436–41.
13. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: self-report versus nurse interview. Public Health Nurs 1991;8(4):245–50. 14. Keeling J, Birch L, Green P. Pregnancy counselling clinic: a questionnaire survey of intimate partner abuse. J Fam Plann Reprod Health Care 2004;30(3):165–8. 15. Espinosa L, Osborne K. Domestic violence during pregnancy: implications for practice. J Midwifery Womens Health 2002;47(5):305–17. 16. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985; 66:185–90. 17. Bullock L, McFarlane J. The prevalence and characteristics of battered women in a primary care setting. Nurse Pract 1989;14(6):47–56. 18. Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990; 80:575–9. 19. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study, Am J Public Health 1987; 77:1337–9. 20. Janssen P, Dascal-Weichhendler H, McGregor M. Assessment for intimate partner violence: where do we stand? J Am Board Fam Med 2006; 19: 413–5. 21. Feuillets d’information. La Clinique de Planning de Rimouski et Pierre-Luc Babin/ The Family Planning Clinic in Rimouski. [Website in French] Available at: http://planning.plbabin.com/feuillets.php Accessed March 12, 2007. 22. The Peel Committee Against Woman Abuse. Website. Available at: http://www.pcawa.org. Accessed March 11, 2007. 23. METRAC Outreach, violence prevention materials page. The Metropolitan Action Committee on Violence Against Women and Children. Website. Available at http://www.metrac.org/programs/info/prevent.htm. Accessed March 11, 2007.
Appendix We are doing a study on domestic violence. Domestic violence is a frequent problem: it is estimated that one in four women will be physically abused during her lifetime. It can start and become worse during a pregnancy. With this study, we hope to be able to improve services for abused women. This questionnaire is anonymous and your answers will stay confidential. Do you agree to fill it out with me ? Yes o
No o
Questionnaire Have you ever been emotionally or physically abused by your partner or someone important to you? Within the last year, has someone said or done something to humiliate you or to hurt your feelings?
Yes o
No o
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes o
No o
If yes, by whom? partner o ex-partner o relative o stranger o other o Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes o
No o
If yes, by whom? partner o ex-partner o relative o stranger o other o Within the last year, has anyone forced you to have sexual activities?
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o Are you afraid of your partner or anyone you listed above?
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o
MAY JOGC MAI 2007 l
423
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy Dominique Bourassa, MD, Jocelyn Bérubé, MD, MSc Clinique de planification des naissances, Rimouski (Québec)
Abstract Objective: To determine the prevalence of intimate partner violence (IPV) among women and teenagers seeking termination of pregnancy compared with those continuing with pregnancy. Methods: All women who presented for elective termination of pregnancy at a family planning clinic between June 2001 and January 2003 were invited to participate. This study was conducted by means of face-to-face interviews with clinic nurses. The control group was composed of women who were continuing with pregnancy. Results: In total, 1003 women were interviewed, including 350 at the family planning clinic (elective abortion [EA] group) and 653 women at the perinatal clinic (continuing pregnancy [CP] group). For women in the EA group, the probability of being a victim of IPV in the past year (including psychological, physical, and/or sexual abuse) was almost three times higher than for women in the CP group (25.7% vs. 9.3%, P < 0.0001), and the risk of being a victim of physical and/or sexual IPV in the past year was almost four times higher (7.1% vs. 1.8%, P < 0.0001). Women in the EA group had also more often been victims of violence in their lifetime (41.1% vs. 29.1%, P = 0.0001). The principal factors predictive of having been a victim of physical and/or sexual IPV in the past year were being single, separated, divorced, or widowed, and being in a relationship that was in difficulty or breaking down. In the multivariate analysis adjusted for confounding factors, age was rarely a significant factor. Conclusion: The high prevalence rates of IPV among women seeking elective abortion justifies routine assessment for IPV during pre-abortion visits. Physicians have access to tools that will help them to identify IPV and to be proactive regarding this important issue.
Key Words: Intimate partner violence, elective abortion, pregnancy, teenagers Competing Interests: None declared. Received on December 1, 2006 Accepted on February 12, 2007
Résumé Objectif : Déterminer la prévalence de la violence exercée par le partenaire intime (VPI) chez les femmes et les adolescentes qui cherchent à obtenir une interruption de grossesse, par comparaison avec celles qui souhaitent poursuivre leur grossesse. Méthodes : Toutes les femmes qui se sont présentées, entre juin 2001 et janvier 2003, dans une clinique de planification familiale afin d’obtenir une interruption volontaire de grossesse ont été invitées à participer à l’étude. Celle-ci a été menée au moyen d’entrevues directes avec des infirmières cliniques. Le groupe témoin était composé de femmes qui poursuivaient leur grossesse. Résultats : Au total, 1 003 femmes ont été interviewées, dont 350 qui l’ont été à la clinique de planification familiale (groupe « interruption volontaire de grossesse » [IVG]) et 653, à la clinique périnatale (groupe « poursuite de la grossesse » [PG]). Dans le cas des femmes du groupe IVG, la probabilité d’avoir été victime de VPI (y compris la violence psychologique, physique et/ou sexuelle) au cours de l’année précédente était près de trois fois plus élevée que pour les femmes du groupe PG (25,7 %, par comparaison avec 9,3 %, P < 0,0001), tandis que le risque d’avoir été victime de VPI physique et/ou sexuelle au cours de l’année précédente était près de quatre fois plus élevé (7,1 %, par comparaison avec 1,8 %, P < 0,0001). Les femmes du groupe IVG avaient également été plus souvent victimes de violence au cours de leur vie (41,1 %, par comparaison avec 29,1 %, P = 0,0001). Les principaux facteurs permettant de prédire le fait que la patiente avait été victime de VPI physique et/ou sexuelle au cours de l’année précédente étaient le célibat, la séparation, le divorce ou le veuvage, ainsi que le fait de vivre une relation connaissant des difficultés ou se détériorant. Dans le cadre de l’analyse multivariée ayant fait l’objet d’une neutralisation des facteurs confusionnels, l’âge constituait rarement un facteur significatif. Conclusion : Les taux élevés de prévalence de la VPI chez les femmes cherchant à obtenir une interruption volontaire de grossesse justifie le recours systématique à une évaluation de la VPI au cours des consultations préavortement. Les médecins ont accès à des outils pouvant les aider à identifier la présence de VPI et à agir de façon préventive à l’égard de cet important problème. J Obstet Gynaecol Can 2007;29(5):415–423 MAY JOGC MAI 2007 l
415
WOMEN'S HEALTH
INTRODUCTION
ntimate partner violence (IPV) is widely recognised as a major social and public health issue. IPV includes psychological, verbal, physical, and sexual abuse, as well as economic deprivation or financial abuse. It does not result from loss of control; rather, it is a way chosen to dominate and assert power over another person. It can be experienced at any age, in either a marital or an extramarital relationship. Violence is a significant cause of morbidity and mortality for women, and women experiencing violence have an increased incidence of substance abuse, mental disorders, chronic physical disorders, and sexual complaints.1
I
Many studies have shown that prevalence rates for violence among pregnant and adolescent women appear to be greater than in non-pregnant women; Canadian surveys of violence against women have found an annual prevalence of 8%, and in a sub-group of women who were abused during pregnancy, 40% reported that the abuse began during pregnancy.2 Studies on this topic in the United States have indicated that the prevalence of domestic violence during pregnancy ranges from 0.9% to 20.1%,3 and women with unplanned pregnancies were four times more likely to be a victim of physical violence (12.1% vs. 3.2%).4 Parker et al. reported that 21% of adolescent females and 14% of adult women report experiencing domestic violence during pregnancy.5 In Canada, the prevalence of physical abuse before pregnancy ranges from 8.5% to 10.9%; during pregnancy, it varies between 5.7% and 6.6%.6,7 Indeed, pregnant women are at greater risk of being victims of domestic violence than they are of developing hypertension, preeclampsia, gestational diabetes, or other prenatal complications for which screening is routine and well-organized.3,8 Women who seek termination of pregnancy seem to be particularly at risk of physical abuse; most pregnancies in these women are unplanned. One study in the US identified a 7.8% rate of physical or psychological abuse during pregnancy, and a prevalence of 21.6% in the previous year9; another described an overall rate of psychological, physical, and sexual violence (including lifetime abuse) of 39.5%.10 In a study conducted in an abortion clinic in British Columbia, the reported rates of physical and sexual violence during the preceding year were 8.3% and 7.1%, respectively; 8.3% of women said that they were afraid of their partners.11 A study of 1145 women presenting to abortion clinics in Ontario showed that more than one quarter of them (26.4%) reported significant conflict in their relationship with the man involved in their pregnancy, 19.5% reported having been physically abused at least once by a male partner, and 27% reported that they had experienced sexual abuse or sexual violence in the past.12 416
l MAY JOGC MAI 2007
The objective of this study was to determine the prevalence of intimate partner violence in women seeking termination of pregnancy and to compare it with the prevalence in women who continued with pregnancy. METHODS
All women who presented for voluntary termination of pregnancy at the Rimouski family planning clinic between June 2001 and January 2003 were invited to participate in this study. We opted to administer the questionnaires during patients’ face-to-face interviews with the clinic nurses (private interview and anonymous questionnaire) rather than offer the women a questionnaire to complete, given the higher rates of disclosure of violence discovered in studies that used the former interview technique.13 The control group comprised pregnant women who chose to continue their pregnancy; all women who met with the perinatal nurse for their routine interview, usually during the first trimester, were invited to participate in the study. The two nurses at the family planning clinic and the perinatal nurse had been given training in routine assessment and intervention for victims of IPV, as well as in interviewing participants using the questionnaire. Flyers on the subject of IPV and available resources were given to all participants after the interview. Women who were identified as victims of IPV were offered follow-up with the family planning clinic’s social service professional, as well as more detailed verbal explanations of various subjects related to IPV (types of violence, cycle of violence, escalation, and protection scenario). The study questionnaire was adapted from the Abuse Assessment Screen, a previously validated screening instrument frequently used in studies of IPV (Appendix). A section on sociodemographic data was added to the questionnaire, as well as a question on psychological violence. Three dependent variables were analyzed in this study: victims of lifetime abuse (who answered yes to question 1); victims of intimate partner violence within the last year (who answered yes at least once to at least one of questions 2, 3, and 5 [question 4 is included in question 3], indicating if it was their partner or ex-partner); and victims of physical and/or sexual intimate partner violence within the last year (who answered yes to questions 3 or 5, indicating if it was their partner or an ex-partner). Simple associations between sociodemographic variables and dependent variables were first measured with the chi-square test for each variable individually (univariate analysis). Subsequently, the joint effect of each variable for which a simple association had been detected was measured using logistic regression models (multivariate analysis). All statistical tests were performed with a threshold for significance of 5%.
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
RESULTS
Two women who chose abortion and two who chose to continue their pregnancies refused to participate. In total, 1003 women were interviewed, including 350 at the family planning clinic (elective abortion [EA] group) and 653 women at the perinatal clinic (continued pregnancy [CP] group). The demographic characteristics of participants are presented in Table 1. Women in the EA group differed on all points from the CP group: they were younger, more often single or in a relationship that was in difficulty or breaking down, were less educated, and had lower incomes. They were more likely to have had a previous abortion, and their current pregnancy was more likely to be unplanned. The prevalence of different types of violence is shown in Table 2. Women in the EA group were at significantly greater risk of having been victims of most types of abuse measured, including lifetime abuse, and of psychological, physical, and sexual abuse in the past year, and they were also more likely to express fear. The prevalence of physical abuse during pregnancy was similar in each group. In most cases, partners and ex-partners were responsible for the violent actions. Of women who identified their partners and/or ex-partners as the perpetrators of the acts of violence, women in the EA group were at higher risk, with a prevalence ratio of 1.41 for lifetime abuse, 2.75 for IPV in the past year, and 3.88 for physical and/or sexual IPV in the past year. The distribution of domestic violence variables is shown in Figure 1. Factors predictive of having been a victim of physical and/or sexual IPV in the past year (odds ratio) are shown in Table 3. Single women and women who were separated, divorced, or widowed were at significantly higher risk of having experienced abuse in the past year, particularly among the CP group. The other principal predictive factors were being in a relationship that was in difficulty or that was breaking down, the number of pregnancies, and having planned the pregnancy and being in the EA group. Concerning the variable “pregnancy planned,” 50% of the 12 women who had planned their pregnancy and were seeking termination had been victims of physical and/or sexual IPV in the past year; this figure contrasts with 5.6% among the 337 women whose pregnancy had not been planned and who were seeking termination. The trend was reversed for the group who continued their pregnancy (Table 4). Because there were few young adolescents in each group, we included them with young women aged 18–19 years to increase the statistical strength of the analyses related to the variable “patient’s age.” In the group of women seeking elective abortion, those under 20 years of age had less often been victims of lifetime abuse and of IPV (psychological,
physical, or sexual) in the past year than older women, but there was no significant difference regarding the variable physical and/or sexual IPV in the past year. Women under 20 years of age who continued their pregnancies had more often been victims of lifetime abuse than their older counterparts and than women under 20 who sought elective abortion (50% vs. 26.9%). In the group pursuing pregnancy, the prevalence of domestic abuse in the past year (psychological, physical, or sexual) and of domestic physical, and/or sexual abuse in the past year were higher in women under 25 years of age than in older women (Figure 2 and Tables 5, 6, and 7). In the multivariate analysis adjusted for confounding factors, association with age was rarely significant. DISCUSSION
Routine assessment for intimate partner violence, especially among pregnant women, has been recommended by a number of organizations, including the Society of Obstetricians and Gynaecologists of Canada in 1996 and again more recently in their Intimate Partner Violence Consensus Statement.1 To our knowledge, this study is the first that was designed to compare women seeking abortion with women continuing pregnancy. It is also the first profile concerning IPV for pregnant women and teenagers in Quebec. The risk of being a victim of IPV in the past year (including psychological, physical, and/or sexual abuse) was almost three times higher for women in the EA group than for women in the CP group, and the risk of being a victim of physical and/or sexual intimate partner violence in the past year was almost four times higher. These women have also more often been victims of lifetime violence. This situation can be partly attributed to the demographic characteristics of women in the EA group, who were more often separated, divorced, or widowed and more often in a relationship that was in difficulty or breaking down (corresponding to the major predictive factors listed in Table 3). We can also presume that a woman who is victim of IPV might have less control over choice of contraceptive method, and even less so in a context of sexual abuse, thus leading to a greater proportion of unplanned or unwanted pregnancies and women seeking a termination of pregnancy. Of the 466 women with unplanned pregnancies, 337 (72%) sought elective abortion. Several earlier studies on the prevalence of domestic abuse in a context of prenatal visits had listed unplanned pregnancy among the risk factors for abuse; in one of these, the risk of violence in a sub-group of women with unplanned pregnancies was four times higher.3 In our study, the prevalence of domestic abuse among women who continued their pregnancy was indeed much higher for those whose pregnancy had been unplanned than for women whose pregnancy was planned (7.8% vs. 0.4%). MAY JOGC MAI 2007 l
417
WOMEN'S HEALTH
Table 1. Comparative sociodemographic data for women who had elective abortions (EA) versus those who continued their pregnancies (CP) EA Group Sociodemographic data Woman’s average age Civil status Single Married Commom law Separated Divorced Widow Level of education Primary Secondary (regular) Secondary (professional / adult) College University Personal income Less than $999 $1000 to $9999 $10 000 to $19 999 $20 000 to $29 999 $30 000 to $39 999 $40 000 to $49 999 $50 000 and over Number of pregnancies 1 2 3 4 5 6 7 8 9 10 Previous elective abortions 0 1 2 3 4 5 Average age of partner Age of the pregnancy 5 to 9 weeks 10 to 14 weeks 15 to 26 weeks 27 to 36 weeks Pregnancy planned Yes No State of the couple Stable In difficulty Separating Separating eventually Does not apply
n
l MAY JOGC MAI 2007
%
n
Statistics %
c2 P < 0.0001 P < 0.0001
28.0
25.3 189 20 104 27 9 1
54.0 5.7 29.7 7.7 2.6 0.3
62 139 441 5 6 0
9.5 21.3 67.5 0.8 0.9 0.0
79 116 43 79 33
22.6 33.1 12.3 22.6 9.4
69 117 89 187 191
10.6 17.9 13.6 28.6 29.2
51 91 128 43 25 6 6
14.6 26.0 36.6 12.3 7.1 1.7 1.7
42 88 188 134 115 56 30
6.4 13.5 28.8 20.5 17.6 8.6 4.6
143 72 67 39 14 8 3 3 1 0
40.9 20.6 19.1 11.1 4.0 2.3 0.9 0.9 0.3 0.0
253 214 108 36 26 11 4 0 0 1
38.7 32.8 16.5 5.5 4.0 1.7 0.6 0.0 0.0 0.2
243 79 21 5 1 1 28.1
69.4 22.6 6.0 1.4 0.3 0.3
555 75 18 2 1 2 30.9
85.0 11.5 2.8 0.3 0.2 0.3
241 104 0 0
69.9 30.1 0.0 0.0
89 493 47 24
13.6 75.5 7.2 3.7
12 337
3.4 96.6
522 129
80.2 19.8
211 27 45 9 58
60.3 7.7 12.9 2.6 16.6
619 12 19 1 2
94.8 1.8 2.9 0.2 0.3
P < 0.0001
P < 0.0001
P < 0.0001
P < 0.0001
P < 0.0001 P < 0.0001
P < 0.0001
Missing values have been removed from the totals.
418
CP Group
P < 0.0001
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
Table 2. Detailed distribution of rates of violence Elective abortion (350)
Q-1 Victim of lifetime abuse Q-2 Psychological abuse past year (total) partner/ex-partner parent stranger others Q-3 Physical abuse, past year (total) partner/ex-partner parent stranger others Q-4 Physical abuse during pregnancy (total) partner/ex-partner parent others Q-5 Sexual abuse, past year (total) partner/ex-partner others Q-6 Fear (total) partner/ex-partner parent stranger others Variable: “Intimate partner violence in the past year” Variable: “Physical and/or sexual intimate partner violence in the past year”
Continuing pregnancy (653)
P
%
n
%
n
41.14%
(144)
29.10%
(190)
0.0001*
36.57%
(128)
19.60%
(128)
< 0.0001*
25.43% 2.60% 2.30% 6.20%
(89) (9) (8) (22)
9.20% 3.10% 0.90% 6.30%
(60) (20) (6) (41)
< 0.0001*
7.71%
(27)
2.30%
(15)
< 0.0001*
5.71% 0.30% 0.90% 0.30%
(20) (1) (3) (1)
1.50% 0.20%
(10) (1)
0.0002*
0.60%
(4)
1.14%
(4)
1.23%
(8)
1.000*
0.86% 0.30%
(3) (1)
0.80%
(5)
1.000*
0.50%
(3)
4.30%
(15)
0.60%
(4)
< 0.0001*
3.20% 1.10%
(11) (4)
0.50% 0.20%
(3) (1)
0.0003*
12.03% 8.60% 0.90% 0.30% 1.70% 25.71%
(42) (30) (3) (1) (6) (90)
7.20% 4.90% 1.80%
(47) (32) (12)
0.0140*
0.20% 9.34%
(1) (61)
P < 0. 0001*
7. 14%
(25)
1.84%
(12)
P < 0. 0001*
*Calculated using Fisher exact test
However, this association was reversed among women who had sought abortions. It is interesting to note that the prevalence of physical and/or sexual IPV in the past year is similar for women with an unplanned pregnancy in each group studied. In the analysis of the factors predictive of being a victim of physical and/or sexual IPV in the past year, only having a planned pregnancy in the EA group was significant, with an odds ratio of 16.05. Of the eight women who had been victims of physical and/or sexual IPV in the past year and who had planned their pregnancy, six sought termination. We can hypothesize that these women, once pregnant, decided not to bring a child into the world under conditions of violence.
Rates of physical abuse during pregnancy were similar in each group (1.14% in the EA group and 1.23% in the CP group), and were lower than those reported by Muhajarine7 (adjusted rate of physical violence during the second and third trimesters of pregnancy 4.5%) and Stewart6 (physical abuse during pregnancy 6.6%). Notably, our interviews with all women in the EA group and with 89.1% of women in the CP group were conducted in the first trimester; the prevalence of violence during pregnancy for the CP group might have been higher if the interviews had been repeated later in pregnancy. In the EA group, the prevalence of physical abuse in the past year was 7.7%, for sexual abuse in the past year was MAY JOGC MAI 2007 l
419
WOMEN'S HEALTH
Figure 1. Prevalence of Intimate Partner Violence (IPV) Variables
Figure 2. Lifetime Abuse Prevalence, by Patient's Age
4.3%, and 8.6% reported being afraid of their partner or ex-partner. These rates are comparable to those found in a study undertaken at a Vancouver abortion clinic.10 Prevalence rates for lifetime abuse in the EA group (41.4%) and the CP group (29.1%) were similar to those obtained in abortion clinics in the United States (39.5%)9 and in England (35.1%).14 At the outset, we hypothesized that teenagers who sought abortion were at greater risk of being victims of violence (physical, sexual, and psychological abuse). Instead, we observed the opposite in the EA group, with the prevalence of different types of abuse increasing with age (Tables 5, 6, and 7). Instead, the CP group of women under 20 had the highest prevalence of lifetime abuse. In the multivariate analysis adjusted for confounding factors, the association 420
l MAY JOGC MAI 2007
between age and abuse was rarely significant. The reported association between age and prevalence of abuse is variable, with some studies reporting a higher prevalence of physical abuse among younger women,6,15–17 and others finding no association.7,18,19 Our study has certain limitations. Underreporting is the first bias that can be identified in a study on the prevalence of IPV. We attempted to weaken this bias by opting for direct interviews, which have been shown to increase reporting rates.13 The second question used on the Abuse Assessment Screen (on psychological abuse) was not validated, unlike the five other questions. For this reason, we performed our analyses, including the multivariate analysis to determine the odds ratio, using the variable “physical and/or sexual IPV in the past year.” Finally, the variable “lifetime abuse”
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
Table 3. Odds ratios for factors predictive of having been a victim of physical and/or sexual abuse in the past year (multivariate analysis) Demographic variable
Elective abortion
19 years old and under*
0.24 (0.04–1.51)
20–24 years old*
0.44 (0.10–1.87)
25–29 years old*
0.72 (0.17–3.03)
Continuing pregnancy
30–34 years old*
0.06 (0.01–0.77)
Single†
3.02 (0.72–12.62)
21.29 (1.94–233.36)
Separated-divorced-widowed†
6.65 (1.22–36.26)
25.72 (1.15–573.36)
2nd pregnancy‡
8.44 (1.95–36.60)
2.78 (0.35–21.91)
3rd pregnancy‡
4.58 (0.96–21.85)
11.76 (1.45–95.11)
4th pregnancy‡
6.17 (1.30–29.40)
7.58 (0.82–70.02)
23.36 (4.85–112.59)
0.275 (0.05–1.55)
Pregnancy planned§ Pregnancy unplanned2
0.04 (0.01–0.21)
3. 64 (0.65–20.41)
Couple having difficulties¶
4.57 (1.08–19.35)
10.72 (1.29–89.07)
Couple separating¶ (include separating eventually)
4.39 (1.42–3.56)
8.49 (1.48–48.69)
Data presented according to odds ratio estimates (95% Wald confidence limits). *reference category is “over 35 years old” †reference category is “married/common-law” ‡reference category is “1st pregnancy” §reference category is “pregnancy unplanned” 2reference category is “pregnancy planned” ¶reference category is “stable couple” Data in bold are statistically significant.
Table 4. Prevalence of domestic physical and/or sexual abuse in the past year, according to whether or not the pregnancy was planned Victim of domestic physical and/or sexual abuse in the past year Elective abortion (25)
Continuing pregnancy (12)
P
Pregnancy planned (534)
50% (6/12)
0.4% (2/522)
< 0.0001*
Pregnancy unplanned (466)
5.6% (19/337)
7.8% (10/129)
0.40
P < 0.0001*
P < 0.0001*
Statistical tests *Calculated using Fisher exact test
does not include women who answered “no” to the first question (lifetime violence) and “yes” to the other questions (psychological, physical, or sexual abuse within the last year). Therefore, it is possible that women who were abused but did not consider themselves to be may not have been accounted for in the analyses. However, after examining the questionnaires, we found that only five women from the EA group and four from the CP group provided this pattern of answers; this would not have significantly changed the total number of positive responses to the first question. Women who are abused during pregnancy are more likely to be depressed and suicidal and to experience pregnancy
complications and poor outcomes, including maternal and fetal death.1 Certain risk factors identified in this study could be used as indicators (single, separated/ divorced/widowed, unplanned pregnancy, relationship in difficulty or breaking down), but there is no typical portrait of women who are victims of violence. One study has shown that women who had been given advice during their pregnancy on how to ensure their safety in situations of violence were subsequently able to reduce their exposure to violence.5 Larger studies should continue to evaluate effective strategies and preventive measures. But while waiting for definitive studies before attempting MAY JOGC MAI 2007 l
421
WOMEN'S HEALTH
Table 5. Prevalence of lifetime abuse, by patient’s age Victim of lifetime abuse Patient’s age
Elective abortion
Continuing pregnancy
P
19 years and under
26.9% (18/67)
50% (9/18)
0.11
20–24 years
39.7% (50/126)
40.6% (58/143)
0.98
25 years and over
48.4% (76/157)
25% (123/492)
0.0000001
P = 0.01
P = 0.0002
Statistical tests
Table 6. Prevalence of intimate partner violence in the past year, by patient’s age Victim of intimate partner violence in the past year Patient’s age
Elective abortion
Continuing pregnancy
P
19 years and under
16.4% (11/67)
11.1% (2/18)
0.726*
20–24 years
22.2% (28/126)
18.2% (26/143)
0.50
25 years and over
32.5% (51/157)
6.7% (33/492)
< 0.0001
P = 0.022
P = 0.0002
Statistical tests *Calculated using Fisher exact test
Table 7. Prevalence of physical and/or sexual intimate partner violence in the past year, by patient’s age Victim of physical and/or sexual intimate partner violence in the past year Paent’s age
Elective abortion
Continuing pregnancy
P
19 years and under
4.5% (3/67)
5.6% (1/18)
0.621*
20–24 years
6.4% (8/126)
5.6% (8/143)
0.997
25 years and over
8.9% (14/157)
0.6% (3/492)
< 0.0001*
P = 0.453
P = 0.0002
Statistical tests *Calculated using Fisher exact test
interventions, we must not ignore the ability of victims themselves to find solutions. Simple identification of the problem and a supportive relationship with a physician may help women to leave a dangerous situation or to reduce harm to themselves and their children.20 Training programs on assessment and interventions for victims of IPV should be easier to access and adapted to the needs of different health professionals, including physicians. The instrument used in this study and adapted from the Abuse Assessment Screen includes only six questions to ask the patient when her partner is not with her; it is quick and easy to use. Other tools are easily accessible, including the IPV Assessment Toolkit1 available on the SOGC website. Flyers on IPV are available in French and English 422
l MAY JOGC MAI 2007
from the websites of the Family Planning Clinic in Rimouski,21 the Peel Committee Against Woman Abuse,22 and the Metropolitan Action Committee on violence against women and children.23 CONCLUSION
Putting an end to violence against women and children is everyone’s responsibility. Given the high prevalence rates of intimate partner violence among women seeking elective abortion, we believe that assessment for IPV during pre-abortion visits is justified, as it is during prenatal routine visits. Physicians and all other health care providers now have access to tools that enable them to be proactive on IPV.
The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy
12. Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D. Characteristics of women undergoing repeat induced abortion. CMAJ 2005;172(5):637–41.
REFERENCES 1. Cherniak D, Grant L, Mason R, Moore B, Pellizzari R. Intimate partner violence consensus statement. SOGC Clinical Practice Guidelines, No. 157, April 2005. J Obstet Gynaecol Can 2005;27(4):365–88. Available at: http://www.sogc.org/guidelines/index_e.asp#SSI. Accessed March 11, 2007. 2. Burge VP, Locke D, eds. Family violence in Canada: a statistical profile. Ottawa: Canadian Centre for Justice Statistics, Statistics Canada; 2000. 3. Gazmarian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275(24):1915–20. 4. Gazmarian JA, Adams MM, Saltzman LE, Johnson, CH. Bruce FC, Marks JS. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85(6):1031–8. 5. Parker B, McFarlane J, Soeken K, Silva C, Reel S. Testing an intervention to prevent further abuse to pregnant women. Res Nurs Health 1999;22:59–66. 6. Stewart DE, Cecutti A. Physical abuse in pregnancy. CMAJ 1993;149(9):1257–63. 7. Muhajarine N, D’Arcy C. Physical abuse during pregnancy: prevalence and risk factors. CMAJ 1999;160(7):1007–11. 8. Health Canada. A handbook for health and social service professionals responding to abuse during pregnancy. Ottawa, Minister of Public Works and Government Services, Canada; 1999. 9. Evins G, Chescheir Nl. Prevalence of domestic violence among women seeking abortion services. Women’s Health Issues 1996;6:204–10. 10. Glander SS, Moore ML, Michielutte R, Parsons LH. The prevalence of domestic violence among women seeking abortion. Obstet Gynecol 1998;91(6):1002–6. 11. Wiebe ER, Janssen P. Universal screening for domestic violence in abortion. Women’s Health Issues 2001;11(5):436–41.
13. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: self-report versus nurse interview. Public Health Nurs 1991;8(4):245–50. 14. Keeling J, Birch L, Green P. Pregnancy counselling clinic: a questionnaire survey of intimate partner abuse. J Fam Plann Reprod Health Care 2004;30(3):165–8. 15. Espinosa L, Osborne K. Domestic violence during pregnancy: implications for practice. J Midwifery Womens Health 2002;47(5):305–17. 16. Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol 1985; 66:185–90. 17. Bullock L, McFarlane J. The prevalence and characteristics of battered women in a primary care setting. Nurse Pract 1989;14(6):47–56. 18. Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990; 80:575–9. 19. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study, Am J Public Health 1987; 77:1337–9. 20. Janssen P, Dascal-Weichhendler H, McGregor M. Assessment for intimate partner violence: where do we stand? J Am Board Fam Med 2006; 19: 413–5. 21. Feuillets d’information. La Clinique de Planning de Rimouski et Pierre-Luc Babin/ The Family Planning Clinic in Rimouski. [Website in French] Available at: http://planning.plbabin.com/feuillets.php Accessed March 12, 2007. 22. The Peel Committee Against Woman Abuse. Website. Available at: http://www.pcawa.org. Accessed March 11, 2007. 23. METRAC Outreach, violence prevention materials page. The Metropolitan Action Committee on Violence Against Women and Children. Website. Available at http://www.metrac.org/programs/info/prevent.htm. Accessed March 11, 2007.
Appendix We are doing a study on domestic violence. Domestic violence is a frequent problem: it is estimated that one in four women will be physically abused during her lifetime. It can start and become worse during a pregnancy. With this study, we hope to be able to improve services for abused women. This questionnaire is anonymous and your answers will stay confidential. Do you agree to fill it out with me ? Yes o
No o
Questionnaire Have you ever been emotionally or physically abused by your partner or someone important to you? Within the last year, has someone said or done something to humiliate you or to hurt your feelings?
Yes o
No o
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes o
No o
If yes, by whom? partner o ex-partner o relative o stranger o other o Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes o
No o
If yes, by whom? partner o ex-partner o relative o stranger o other o Within the last year, has anyone forced you to have sexual activities?
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o Are you afraid of your partner or anyone you listed above?
Yes o
No o
If yes, who? partner o ex-partner o relative o stranger o other o
MAY JOGC MAI 2007 l
423